Integrated Care Coach & Patient Navigator (Field Roles)

humana; New Braunfels (TX); Hybrid; USD 60,000 - 90,000; Full time

Job summary

Humana is seeking a Care Coach in Texas to provide proactive, patient-centered care coordination and social needs support for high-risk patients within the Primary Care network.

You will conduct home visits, coordinate with providers, manage transitions of care, and reinforce care plans while traveling to patients' homes and clinic sites. The role requires in-person outreach and a commitment to culturally competent care for diverse communities.

Qualifications

• 3+ years of ambulatory or primary care patient care required.
• Ability to discuss chronic conditions and reinforce instructions.
• Comfort with regular home visits and community outreach.
• Experience in patient education, care coordination, and social support for high-risk or geriatric populations.

Responsibilities

• Clinical Screening & Escalation: conduct structured patient interviews and collect health information; document findings.
• Outreach and Home Visits: perform home visits to observe living conditions and safety concerns.
• Social Needs support: identify barriers and connect patients with community resources.
• Chronic Disease Education: deliver culturally appropriate education to reinforce recommendations.
• Care Coordination: liaise between patients, primary care, specialists, pharmacies, home health, and community providers.
• Post-Hospital and ED Follow-Up: conduct timely follow-up after hospitalizations/ED visits.
• Community Engagement: encourage patient connection to community programs.
• Cultural Competence: deliver culturally sensitive care respecting beliefs and contexts.
• Develop holistic understanding via 5Ms framework; prepare for High-Risk Rounds.

Skills

Care coordination

Patient education

Home visits

Chronic disease management

Cultural competence

Education

LPN/LVN license

RN license

MA Certification

Job description

Humana is seeking a Care Coach in Texas to provide proactive, patient-centered care coordination and social needs support for high-risk patients within the Primary Care network.

You will conduct home visits, coordinate with providers, manage transitions of care, and reinforce care plans while traveling to patients' homes and clinic sites. The role requires in-person outreach and a commitment to culturally competent care for diverse communities.